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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. / `-'�,,� Job'Address D(73(fI J�.�•�-�7 r� City Lot Size 4 —PM Owner's Name �� Address �,Alf Phone r � Z ContractorAddress License No. 1 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT * DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Ct Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Delxh' '•.'~ Filler Material (Below 501 TYPE OF SEPTIC WORK: iNEW INSTALLATION ❑ 'REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is tIw available within 200 feet.) I Installation will,serve: Residence- Commercial— Other ` Number of living units:- Number of bedFpoms-�---' Character of,soil to a depth of 3 feet: ` '_ Water table depth SEPTIC TANK ❑1 Type/Mfg s Capacity No. Compartments , PKG. TREATMENT PLT. 0 �__ — . � � Method of Disposal I Distance to nearest: Well 17 Fotyndation %0 Property Line �60 / Vilt I LEACHING LINE '44,, ❑*sNo. & Length of lines 1- Total length/size 120 d +7 Foundation Property Line ,r1 r FILTER BED ❑ Distance to nearest: Well �)� SEEPAGE PITS El Depth' ri rfi Size + - " + Number SUMPS ❑ Distance to nearest: Well L_9_.A Foundations PropertyRLine DISPOSAL PONDS ❑ `" I hereby certify that I have prepared this application and that the work will be,done in accordance with San Joaquin county-ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all require spections. Comple drawing on rse side. Signed X 4L5;'r r Title: _ _ Date: Z P11 FO DEPARTMENT USE ONLY Application Accepted by Date L r3 to Area Pit or Grout Inspection b Date Final Inspection Date`�� ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 55201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24 IREV.1/851 � 1 (16 y �� >� EH 14-26 /9,